Stroke Advocacy Network

Medicare Therapy Cap
Exceptions Process Set to Expire

Unless Congress takes action before December 31, 2011, some Medicare beneficiaries will lose access to critical speech, physical and occupational therapy services. Why is this coverage at risk?

In 1997, Congress sought to control Medicare spending. One way they accomplished this was by limiting, or capping, the amount of money Medicare spends per person, per year on speech, physical and occupational therapy obtained outside the hospital. Congress set annual caps for these services—in 2012, those caps are $1,880 for physical and speech therapy (combined) and another $1,880 for occupational therapy.

After these caps were enacted, Congress recognized that some patients need more therapy services than the capped level of funding provides. In 2006, they created an exceptions process, which allows patients who reach the cap to receive additional therapy services if the services are determined to be medically necessary. Congress has extended, or reauthorized, this process every year since it was created. However, they have not acted to reauthorize it this year. If Congress doesn’t act before December 31, the exceptions process will expire. This means that Medicare will not pay for additional rehabilitation services, even if those services are medically necessary for a stroke survivor’s recovery.

The Stroke Advocacy Network has supported legislation introduced by Senator Ben Cardin (D-MD) and Representative Jim Gerlach (D-PA) to permanently repeal these therapy caps—S. 829 and H.R. 1546, collectively known as the Medicare Access to Rehabilitation Services Act. Our advocates voiced our support for these bills during our 2011 Lobby Day on Capitol Hill this past June. Despite collecting a combined 143 cosponsors (i.e., members of Congress who have stated their support for a certain bill), these bills have stalled in both the House and Senate.

The National Institutes of Health (NIH) conduct vital medical research on many conditions, including stroke, to help identify more effective treatments and prevention strategies. Two months into fiscal year 2012 (FY 2012), the budget for the NIH has yet to be finalized.

Since the beginning of the fiscal year on October 1, Congress has passed a series of short-term funding bills that have kept the federal government, including the NIH, operational while budget negotiations continue. These short-term spending bills have funded the NIH at a level 1.5 percent below last year (FY 2011), and the last of these bills is set to expire on December 16.

In order to finalize a budget for the NIH, Congress typically passes what is called an appropriations bill. There are 12 individual appropriations bills, and each one funds a particular group of federal agencies and departments. This year, both the House and Senate have passed their own versions of the bill that funds NIH in FY 2012, which also funds other programs related to the departments of Labor, Health and Human Services and Education. The Senate version proposes to cut NIH funding by $190 million, while the House version proposes to increase it by $1 billion.

In a regular budget cycle, the House and Senate would come together and work out the differences between their versions of this appropriations bill. Once the House and Senate agree to the same version of the bill, it goes to the President for veto or signature. (Read more about how a bill becomes a law here.) However, this year the House and Senate have been unable to agree on a single version of the bill. At this time, it is unclear how Congress intends to resolve this issue. A likely outcome will be that Congress combines all the remaining appropriations bills, including the one that funds NIH, into what is typically called an omnibus bill. Both the House and Senate would vote on this omnibus bill (instead of voting on all 12 appropriations bills individually). No matter how this issue gets resolved, Congress will be making decisions about NIH funding in the next few weeks.

In October, National Stroke Association asked members of the Stroke Advocacy Network to contact Congress about World Stroke Day. We asked that members of Congress speak out about stroke in honor of World Stroke Day, which was October 29.

Over 450 Stroke Advocacy Network members from 44 different states sent more than 1,500 messages to Capitol Hill. Representatives Lois Capps (D-CA), Virginia Foxx (R-NC) and Carolyn McCarthy (D-NY) answered your calls. Read their statements here: Lois Capps (D-CA), Virginia Foxx (R-NC) and Carolyn McCarthy (D-NY). Additionally, Representative John Larson (D-CT) posted about World Stroke Day on Facebook and Twitter. If any of these members of Congress represent you, please contact them by email, phone, Facebook or Twitter to thank them for their support of the stroke community. You can find out who represents you and reach their official congressional Web pages on the Stroke Advocacy Network website or at www.house.gov.

Over the past year, the Stroke Advocacy Network has provided opportunities for you to make your voice heard in Washington, D.C. on stroke-related policy issues. In 2012, the Stroke Advocacy Network is expanding into a statehouse near you!

Our new state advocacy Web pages will allow you to follow stroke-related legislation being debated in your state. The pages will include information about your state’s legislature, who represents you at the state level, stroke-related legislation being considered and how you can watch and participate in your state’s legislative process.

Watch for future announcements about this new feature of the Stroke Advocacy Network’s website, and prepare to make your voice heard at home as well as on Capitol Hill.